Mental StressYInduced Ischemia in Patients With Coronary Artery Disease: Echocardiographic Characteristics and Relation to Exercise-Induced Ischemia (original) (raw)
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Mental Stress-Induced Ischemia in Patients With Coronary Artery Disease
Psychosomatic Medicine, 2012
Objective: The aims of this study were to investigate the incidence and parameters associated with myocardial ischemia during mental stress (MS) as measured by echocardiography and to evaluate the relation between MS-induced and exercise-induced myocardial ischemia. Methods: Study participants were 79 patients (63 men; mean [M] [standard deviation {SD}] age = 52 [8] years) with angiographically confirmed coronary artery disease and previous positive exercise test result. The MS protocol consisted of mental arithmetic and anger recall task. The patients performed a treadmill exercise test 15 to 20 minutes after the MS task. Data of postYMS exercise were compared with previous exercise stress test results. Results: The frequency of echocardiographic abnormalities was 35% in response to the mental arithmetic task, compared with 61% with anger recall and 96% with exercise ( p G .001, exercise versus MS). Electrocardiogram abnormalities and chest pain were substantially less common during MS than were echocardiographic abnormalities. Independent predictors of MS-induced myocardial ischemia were: wall motion score index at rest ( p = .02), peak systolic blood pressure ( p = .005), and increase in rate-pressure product ( p = .004) during MS. The duration of exercise stress test was significantly shorter p G .001) when MS preceded the exercise and in the case of earlier exercise (M [SD] = 4.4 [1.9] versus 6.7 [2.2] minutes for patients positive on MS and 5.7 [1.9] versus 8.0 [2.3] minutes for patients negative on MS). Conclusions: Echocardiography can be successfully used to document myocardial ischemia induced by MS. MS-induced ischemia was associated with an increase in hemodynamic parameters during MS and worse function of the left ventricle. MS may shorten the duration of subsequent exercise stress testing and can potentiate exercise-induced ischemia in susceptible patients with coronary artery disease. Key words: mental stress, myocardial ischemia, exercise stress echocardiography. MS = mental stress; CAD = coronary artery disease; ECG = electrocardiogram.
American Journal of Cardiology, 2005
To examine the susceptibility to myocardial ischemia with mental stress in patients who have coronary artery disease and normal left ventricular (LV) function versus those who have impaired LV function, we examined 58 patients who had coronary artery disease, including 22 who had normal LV function (ejection fraction >50%), 16 who had mild to moderate LV dysfunction (ejection fraction 30% to 50%), and 20 who had severe LV dysfunction (ejection fraction <30%) and underwent bicycle and mental stress testing with myocardial perfusion scintigraphy on consecutive days in random order. Ischemia was assessed based on summed difference scores in regional rest versus stress myocardial perfusion and defined as a summed difference score >3. At comparable double products across the 3 groups, ischemia was induced with mental stress more frequently in patients who had severe LV dysfunction (50%) than in those who had normal LV function (9%; p <0.01). The frequency of exercise-induced ischemia was different only between those who had mild/moderate LV dysfunction and those who had normal LV function (56% vs 18%, respectively, p <0.05). The pattern of mental stress versus exercise ischemia differed between groups (p <0.02): there was a higher prevalence of mental stress ischemia versus exercise ischemia in patients who had severe LV dysfunction (p ؍ 0.06), a marginally higher prevalence of exercise versus mental stress ischemia in those who had moderate LV dysfunction (p ؍ 0.07), and no difference in mental stress versus exercise ischemia in those who had normal LV function. Thus, at comparable double products during mental stress and similar extent of coronary artery disease, ischemia with mental stress was induced more frequently in patients who had severe LV dysfunction than in those who had normal LV function. These data suggest that mental stress ischemia may be of particular clinical importance in patients who have coronary artery disease and LV dysfunction. ᮊ2005 by Excerpta Medica Inc.
Journal of Nuclear Cardiology, 2008
Background. Mental stress precipitates myocardial ischemia in a significant percentage of coronary artery disease (CAD) patients. Exercise or adenosine stresses produce different physiologic responses and cause myocardial ischemia via different mechanisms. Little is known about the comparative severity and location of myocardial ischemia provoked by these different stressors. In this study we sought to compare the within-individual ischemic responses to mental versus exercise or adenosine stress in a cohort of CAD patients. Methods and Results. All patients underwent mental stress and either exercise or adenosine testing within a 1-week period. Mental stress was induced via a public speaking task. Rest-stress myocardial perfusion imaging was used with all testing protocols. Participants were 187 patients (65 women [35%]) with a documented history of CAD and a mean age of 64 ± 9 years. Mental stress-induced myocardial ischemia (MSIMI) was less prevalent and frequently of less magnitu...
International journal of cardiac imaging, 1998
Transient ischemic episodes at rest in patients with coronary artery disease have been attributed to mental stress. The means to monitor and record cardiac function changes due to mental stress is now available by utilizing the nuclear VEST. Eight, patients with angiographically documented coronary artery disease and 8 normal volunteers underwent a 4 hour session of continuous monitoring and recording of the left ventricular function, electrocardiogram, and blood pressure during exercise and mental stress. In the normal group, all subjects showed the expected normal response to exercise with an increase in ejection fraction, heart rate and blood pressure. During mental stress two subjects (25%) showed transient episodes of ejection fraction decrease that were not associated with chest pain, ST changes or significant changes in blood pressure. In the group of coronary artery disease patients, five (63%) had an ischemic response to exercise by electrocardiographic and radionuclide ven...
Circulatory effects of mental stress during exercise in coronary artery disease patients
1984
We examined the effects of mental stress during steady-state exercise on heart rate, blood pressure, pressure-rate product, and oxygen uptake in 10 coronary artery disease patients. Subjects walked at three mph with grade increases of 4% every two minutes until the target heart rate (60 % peak heart rate from a previous symptomlimited exercise test) was reached. A computerized Stmp-Color-Word Test (mental stress) was added one minute after the subject reached steady-state exercise and lasted 11 5 4 minutes. When mental stress was added to steadystate exercise it significantly (p<O.Ol) increased the heart rate(lOlfl5 to 108f19beatspermin), systolic(154f26 to 170f26 mmHg) and diastolic (86f 10 to 92 f 13 mmHg) blood pressure, and pressure-rate product (158k42 to 179f48 x lo-*). This increase in the mean response during exercise and mental stress was not observed for oxygen uptake (17 f 6 to 18 f5 ml/kg/min). The circulatory changes probably reflect increased sympathetic activity with both centrally mediated cardioacceleratory (and probably cardiac output
American Heart Journal, 1989
CLINICAL INVESTIGATIONS Transient left ventricular dysfunction during provocative mental stress in patients with coronary artery disease We studied the temporal effects of various types of mental stress and physical exercise on the left ventricular ejection fraction (LVEF) in seven normal volunteers and nine patients with coronary artery disease. Three types of psychological stress were administered: mental arithmetic, the Stroop color word test, and a personally relevant speaking task. In the normal volunteers the LVEF response was either flat or increased (p < 0.05) compared to the baseline value during the mental tasks and increased by a mean of 10 + 5% (p < 0.05) during exercise. In contrast, in patients with coronary disease in whom LVEF did not increase 2 5% during exercise, LVEF decreased significantly during the mental tasks (p < 0.05 for arithmetic and Stroop tasks). Typically LVEF decreased quickly during mental stress wlth an immediate rebound after intervention. Decreases in LVEF during mental stress occurred without chest pain and were not associated with ECG changes. In patients with coronary disease in whom LVEF increased normally with exercise (LVEF increase 1 5%), no significant changes in LVEF occurred during mental stress. The heart rate X systolic blood pressure double product during mental stress was significantly less than that achieved during exercise (p < 0.05) in each normal subject and patient. Thus psychological stress can provoke acute decreases in LVEF in patients with coronary disease and exercise-inducible dysfunction. The silent nature of the mental stress-induced abnormalities and their occurrence at a lower physiologic workload compared to abnormalities during exercise parallel characteristics of transient ischemia noted during ambulatory monitoring. Our results show the usefulness of serial left ventricular function monitoring for studying the pathophysiology of silent myocardial ischemia. (AM HEART J 1989;118:1.
The American Journal of Cardiology, 1990
Thirty-seven hdthy type A men (mean age 42 years)wereraahmlya8signedtoeftheranaerobic exercise training groqb or to a strength and ftexibiiity traihg grwrp. Eefore exercise, subjects underwent timpdm&e pbysidegk and behaviord S, hckding graded exercise treadmill testing with direct meawremeM of oxygen -pt&m (jlo2) and measlmemen t of cardkwasadar (heart rate, systdk and diastolk Mood pressure and rate pressure product) and neuoendocrina(epinapMnc~norepinsphrhre)-~ to mental atfthmetic. The aerobic exercise consist-edofwalkiqgsndjo&ngatanintendtyof170% maximal heart rate rosenfefoflhow3times/ week for 12 canse&he weeks. The shngth train-iqgumsist~oflhouofcircuitNau6lurtrainfng2 times/weekforl2weeks.AtthecompMhofthe exercise pcogcam, all subjects umhwent repeat testing. Far the aeroWc groq~, peak \iOz increased . 46&hnUy from 33.6 to 36.4 ml/kg/min (p <O.ool), wimmas the stmngth group only adlieved asliiincrease from 34.5 to 35.6 mlhg/min (differencenot signWad).
Mental stress–induced myocardial ischemia: Moving forward
Journal of Nuclear Cardiology, 2007
See related article, p. 308 The article by Hassan et al 1 in this issue of the Journal is the latest description of a phenomenonmental stress-induced myocardial ischemia (MSIMI)that has been growing in recognition in the cardiology community. This clinical presentation has been historically and consistently explored and brought to the attention of our peers by the efforts of those engaged in clinical research using nuclear cardiology approaches. Among the first descriptions of this form of provoked ischemia in the laboratory was that of Deanfield et al, 2 who used rubidium 82 to image myocardial perfusion via positron emission tomography. This study reported that 12 of 16 patients evidenced a flow defect during the performance of a mental arithmetic task. Of note, the defect associated with mental arithmetic was comparable in size and location to that observed during exercise, although in many cases there were enough differences in the extent and severity of the observed defect to indicate possible differences between MSIMI and exerciseinduced myocardial ischemia in underlying pathophysiology. More recent work has identified the importance of impaired myocardial blood flow, particularly in the microvascular bed, with regard to MSIMI, 3-5 as well as the prognostic significance of this phenomenon. 6-8 Indeed, in the PIMI (Psychophysiological Investigations of Myocardial Ischemia) multicenter study, the investigators found a 3-fold rate ratio of death at 5 years among those who demonstrated MSIMI in the laboratory, as compared with those who did not, controlling for standard risk factors for death. 9 Other work has identified anger, as well as the ease with which one experiences this emotion when under stress, as a vulnerability marker